CPR Registration -Register in 3 easy steps

1. Select the date that you would like to attend and complete the form below.
2. Print this page, enclose
payment to BENSALEM EMS.
3. Mail form & payment to:
     NIEC
     P.O. BOX 11176
     Philadelphia, PA 19136
IMPORTANT: Please see the descriptions of each course on the CPR page to be sure
that you are registering for the correct course.

HeartSaver CPR (Adult and/or pediatric)
Fees are:    $65.00 with book
                  $55.00 without book                                   (Circle One)
 

Please choose a date:
   

Health Care Provider (approx. 4-5 hours for full course, 3 hours for recert)

  Fees are:      $115.00 including book and pocket mask
                      $105.00 with book only                                      (Circle One)
                      $105.00 with pocket mask only
                      $95.00 if neither book or pocket mask is needed
                     (The pocket mask is required. You may bring your own with you).

 Please choose a date:
   

Name:

Address:

City: State:   Zip:

Phone (Day):   Evening:

E-mail (required):  

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